SSA-731 Notice to Electronic Information Exchange Partners to Pr

Form SSA-731 (12-2019)
Social Security Administration

Page 1 of 3
OMB No. XX-XXXX

Notice to Electronic Information Exchange Partners to Provide Contractor List
Government
Federal
(State)

Non-Government
Other (Please specify)

State
Local

(Name of Organization)

Foreign
Tribal

The Social Security Administration (SSA) requires any organization with an electronic data exchange
agreement, to provide the SSA Regional Office contact a current list of contractors and/or agents who have
access to SSA data upon request and the attached Agency Attestation of Contractor Use Form.
For the purpose of this form, the term "organization" refers to state or local agencies, territories, tribes, or
other entities that have a data exchange agreement with SSA.
Data exchange agreements include:
• Computer Matching Agreement (CMA)
• Information Exchange Agreements for federally funded benefit programs (IEA-F)
• Information Exchange Agreement for state funded benefit programs (IEA-S)
• Reimbursable Information Exchange Agreement (R-IEA)
• State Transmission/Transfer Component (STC) agreement
• Social Security Online Verification (SSOLV) agreement
• Memorandum of Understanding (MOU)

Please complete the following Agency Attestation of Contract Use Form and Contractor List Form.

Form SSA-731 (12-2019)

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Agency Attestation of Contractor Use Form
Does your organization utilize any contractors with access to SSA data?

Yes

No

• If no, complete Section 2, sign the form at the bottom of this page and return the form to SSA.
• If yes, complete Sections 1 and 2 and the Contractor List Form. Sign the form at the bottom of this page
and return the form to SSA.
SECTION 1
, certifies that the contractors/agents in the Contractor
(Name of Organization)

List Form are currently under contract with and act on behalf of the organization, to process, maintain,
transmit, store, or destroy SSA data.
All contractors/agents listed in the Contractor List Form:
• have been provided with a copy of the SSA/

,
(Name of Organization)

data exchange agreement prior to the initial disclosure of SSA data; and
• are in compliance with the safeguards and dissemination procedures defined in the agreement.

SECTION 2
Within 60 days of a new contractor/agent having access to SSA data or an existing contractor/agent no
, will notify the

longer having access to SSA data, the
(Name of Organization)

SSA Regional Office contact in writing with an updated Agency Attestation of Contractor Use Form and
Contractor List Form.

Date:

Print Name:

Signature (Approving Official) :

Title:

Form SSA-731 (12-2019)

Page 3 of 3

Contractor List Form
Organization Name:

Contracting Company Name

Contractor/Employee Name
(First, Last)

Position/Duties

Location (City & State)